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Participant Registration Form

June 12-16 , 2017 8:30am-12noon St. Marys Catholic Church, Ponca City
Office phone: 580-382-6010 Volunteers are always appreciated. Please call if you are interested.
$10= 1 child, $20=2 children $25= 3+ children Optional t-shirt: $12 each (by May 22nd)
Please return completed form by _June 5th or May 22nd for t-shirt_____________________
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Childs Information:

Name: _________________________________________________________________________

Sex: (circle one) M F Age: __________ Grade in Fall 2017: _________

T-shirt size: (circle one) child sizes : XS S M L / adult sizes: S M L XL

Allergies or medical conditions: _______________________Please complete diocesan form A.

Family Information:

Parents/Guardians Name(s): _______________________________________________________

Address: _______________________________________________________________________

Phone: Hm: __________________ Wk: ___________________ Cell: ____________________

Email: _________________________________________________________________________

Emergency Contact:

Name: _________________________________________________________________________

Phone: __________________________________ Email: _______________________________


I understand that reasonable precautions will be taken to safeguard the health and well being of the participants in this VBS and that I will be notified as
soon as possible in the event of an emergency. In the case of sickness or an accident, I authorize and consent the VBS Team, or other associated
volunteers of the VBS program to obtain medical care from a licensed physician, hospital, or medical clinic for my son/daughter in the event that myself
or other legal guardian(s) cannot be reached. I hereby do release and forever discharge this Diocese, and Parish from all manners of actions, claims
which I or the child named above shall or may have for any reason, arising during my childs attendance of the VBS.
Unless other written instruction is submitted, I also consent to allowing my childs image to be recorded, either by photograph or video, and used during
the VBS week or for future advertisement of Parish VBS programs. Any other use will require your further consent.

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Parent / Guardian Signature Date